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Blood Products Blood Products Etiology of bleeding: Platelet Count and function need to be assessed. Coagulation factors Glycoproteins that are synthesized in the liver (except V and VIII – extrahepatic sites) II, VII, IX and X are vit K dependent

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blood products2
Blood Products
  • Etiology of bleeding:
    • Platelet
      • Count and function need to be assessed.
    • Coagulation factors
      • Glycoproteins that are synthesized in the liver (except V and VIII – extrahepatic sites)
      • II, VII, IX and X are vit K dependent
      • 2 pathways: intrinsic (PTT) and extrinsic (PT)
    • Fibrinolysis
      • Primary fibrinolysis assoc w/ certain urinary tract operations, liver, oral cavity, and post-CPB state.
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Blood Products
  • Etiology of bleeding:
    • Endothelium
    • Mechanical
blood products lab tests
Blood Products – Lab Tests
  • PTT:
    • PTT detects abnormalities in prekallikrein, Factors XII, XI, IX, VIII, X, V, II
    • Prolonged PTT – Hemophilia A & B, Factor XI deficiency, heparin therapy, lupus, acquired anti-8 antibodies
  • PT:
    • PT detects abnormalities in Factors II, V, VII, X and fibrinogen
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Blood Products – Lab Tests
  • Both PT & PTT prolonged:
    • Multiple factors
    • Selective decrease in one or more common pathway factors
    • Fibrinogen level < 60-80 mg/dl
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Blood Products – Lab Tests
  • Thrombin time tests clot formation from fibrinogen – dec if fibrinogen is low or abnormal
  • Bleeding time is variable based on many factors. It is not predictive of surgical bleeding.
    • Measure of qualitative abnormalities in platelet function and deficiencies
  • ACT assesses adequacy of heparinization
  • TEG measures the viscoelastic strength of whole blood as a clot is formed.
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Blood Products
  • Type and screen vs Type and crossmatch:
    • T&S determines ABO and Rh status and the presence of most commonly encountered antibodies – risk of adverse rxn is 1:1000
    • T&S takes about 5 mins
    • T&C determines ABO and Rh status as well as adverse rxn to even low incidence antigens – risk of rxn is 1:10,000
    • T&C takes about 45 mins
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Blood Products
  • T&S:
    • Type O red cells are mixed with pt serum
    • Antibody screen
  • T&C
    • Type O red cells are mixed with pt serum
    • Antibody screen
    • Donor red cells are then mixed with the pt’s serum to determine possible incompatibility
blood products intra op coagulopathies
Blood Products – Intra Op Coagulopathies
  • DIC:
    • Consumptive coagulopathy presenting as excessive bleeding or intravascular thrombosis
    • Consumes:
      • Platelets
      • Fibrinogen
      • Factors – V and VIII most frequently exhausted
    • Diagnosis requires evidence of systemic activation of both procoagulant and fibrinolytic systems, consumption of inhibitors and end organ damage
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Blood Products – Intra Op Coagulopathies
  • DIC:
    • Lab tests:
      • Inc PT/PTT – PT > 15 secs
      • Dec firinogen - < 150 mg% (nml = 150-200)
      • PLT < 150,000
      • Inc D Dimer
      • Inc Fibrin split products
    • Treatment:
      • First treat underlying cause
      • Treat hypovolemia and acidosis
      • Heparin in thrombotic states

If both increased – specificity = 97% & sensitivity = 100%

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Blood Products – Intra Op Coagulopathies
  • Liver Disease:
    •  coagulopathy
      • Dec factors
      • Dec clearance of FSPs  PLT dysfunction
      • Inc fibrinolysis
    • Treatment – replacement of deficient products and admin of DDAVP to enhance PLT fxn
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Blood Products – Intra Op Coagulopathies
  • Dilutional thrombocytopenia
    • After replacement of one entire blood volume, only 40% of PLTs remain
    • One unit of PLTs inc count by 10,000
  • Hemolytic transfusion reaction
    • Suspect in presence of hypotension, hemoglobinuria, or DIC
    • Resp failure, pulm HTN, dec CO have been reported
    • Diagnosis is confirmed by the presence of free Hgb in spun plasma using the direct Coomb’s test
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Blood Products – Intra Op Coagulopathies
  • Hemolytic transfusion reaction
    • Incidence – 1:4,000-6,000; fatal rxn = 1:100,000
    • Treatment:
      • Stop the transfusion
      • Repeat the crossmatch
      • Send off blood for free Hgb, PT, PTT, Fibrinogen
      • Maintain UO with fluids and diuretics
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Blood Products – Intra Op Coagulopathies
  • Vit K deficiency
    • Effects synthesis of factors II, VII, IX, X, and Protein C & S
    • The most common cause of prolonged PT in ICU pts – antibiotics (gut flora), malnutrition, fat malabsorption
    • Emergent therapy - FFP
blood products transfusion risks
Blood Products – Transfusion Risks
  • Infectious risks:
    • HIV – 1:500,000
    • Hep C – 1:103,000
    • Hep B – 1:63,000
  • Clerical risks – 1:12,000
  • Allergic and febrile non-hemolytic reactions
    • Among the most common
    • 1-4% develop urticaria
    • Self-limited
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Blood Products – Transfusion Risks
  • Febrile hemolytic reaction
    • Inc temp, DIC, hypotension, hemoglobinuria
  • Anaphylactic reaction
    • Mediated through antibodies to IgA immunoglobulins that are present in all donor plasma
    • IgA deficient pts require washed PRBCs
    • Wheezing and hypotension
  • Transfusion related sepsis
    • PLT highest risk b/c at room temp – 100% of PLTs > 5 days old have > 100,000 gm of Staph
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Blood Products – Transfusion Risks
  • Transfusion related sepsis
    • Most common sepsis with PRBCs
      • 1. Pseudomonas
      • 2. Serratia
      • 3. Yersinia
  • Transfusion related acute lung injury
    • 0.02% occurrence
    • Pts present with hypoxemia, bronchospasm, acute respiratory distress, bil pulm infiltrates
    • Self-limited – usually resolved in 24-48 hrs
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Blood Products – Transfusion Risks
  • Citrate intoxication
    •  hypocalcemia– hypotension, narrow pulse pressure, inc end diastolic pressure and CVP, tetany
    • Replete calcium
  • Autologous transfusion
    • Best way to avoid transfusion risks
    • Can donate 1 unit/wk for 4 weeks before surgery
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Blood Products – Transfusion Risks
  • Massive blood transfusion
    • Defined as replacement of one or more blood volume in a 24 hr period.
    • Complications (PATCH)
      • Platelets – dec; Potassium – inc
      • ARDS; Acidosis
      • Temp dec
      • Citrate intoxication
      • Hepatitis
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Blood Products
  • Order of transfusion
    • Type specific partial crossmatch
    • Type specific uncrossmatched
    • Type O, Rh- - can be used in emergency situations
  • Transfusion
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Blood Products
  • PRBCs
    • Indications for PRBC transfusion:
      • Only one – Increase O2 carrying capacity
      • 12 million PRBC units transfused/yr and 25% of these are inappropriate transfusions
      • Always indicated for a Hgb <6 . A healthy pt can tolerate an HCT of 20%, but someone with CAD needs an HCT of at least 30%
      • High incidence of MI found in anemic pts, with CAD, post-op
      • 10 ml/kg will inc HCT 10%
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Blood Products
  • PRBCs
    • 75% of transfused RBCs are in the circulation 24 hrs after transfusion
    • PRBC HCT = 60%
    • Preservation
      • CPD-A (citrate, phosphate, dextrose, adenine) – shelf-life = 35 days at 1-6°C
      • ADSOL (adenine, dextrose, saline, mannitol) – shelf-life = 42 days
      • Deglycerolized blood – frozen with glycerol for storage, washed before transfusion
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Blood Products
  • PRBCs
    • Leucocyte-depleted blood
    • Washed – IgA deficient
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Blood Products
  • FFP
    • Contains all soluble coagulation factors
    • Recommended uses:
      • Urgent reversal of warfarin therapy
      • Correction of known coagulation factor deficiencies
      • Correction of microvascular bleeding in the presence on elevated PT, PTT, and after massive transfusion
      • Do not use for volume
      • Antithrombin III def
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Blood Products
  • Cryoprecipitate
    • Indications
      • Replace factor VIII (Hemo A), factor XIII, fibrinogen, fibronectin, and vWF
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Blood Products
  • Platelets
    • Repeated PLT transfusions will lead to anti-PLT antibodies
    • PLT count and activity are effective for about 2 hours in pts with a production defect. Unknown for consumptive pathology.
    • Indications:
      • Pre-op for PLT < 50,000
        • Remember that prophylactic transfusion is ineffective in the face of thromobcytopenia 2° to PLT destruction ( ITP)
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Blood Products
  • Platelets
    • Indications:
      • Pts with microvascular bleeding whose PLT count is < 50,000
      • Pts with a normal PLT count who have PLT dysfunction